RUMAH SAKIT DR CIPTO MANGUNKUSUMO

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DAFTAR TARIF DEPARTEMEN PATOLOGI KLINIK

NO JENIS PELAYANAN TARIF

KELAS 3

KIMIA KLINIK
1 ALBUMIN (ALB) 33,000
2 AMILASE DARAH 100,000
3 AMILASE URIN 100,000
4 AMMONIAK 185,000
5 AMPHETAMIN (SABU-SABU) 50,000
6 ANALISA GAS DARAH 136,000
7 ASAM URAT DARAH 31,000
8 ASAM URAT URIN 31,000
9 BENZODIAZEPIN 50,000
10 BERSIHAN KREATININ 51,000
11 BETA HIDROKSI BUTIRAT 34,000
12 BILIRUBIN TOTAL + DIREK+INDIREK 52,000
13 C0CAIN 50,000
14 CALSIUM DARAH 34,000
15 CALSIUM ION 127,000
16 CALSIUM URIN 34,000
17 CHOLESTEROL HDL 46,000
18 CHOLESTEROL LDL 60,000
19 CHOLESTEROL TOTAL 36,000
20 CK 77,000
21 CKMB 87,000
22 ELEKTROFORESIS PROTEIN 128,000
23 ELEKTROLIT DARAH (Na, K, Cl) 86,000
24 ELEKTROLIT URIN (Na, K, Cl) 86,000
25 FE(SI) + TIBC + UIBC 158,000
26 FOLAT 362,000
27 FOSFAT INORGANIK DARAH 40,000
28 FOSFAT INORGANIK URIN 40,000
29 FOSFATASE ALKALI 38,000
30 FOSFATASE ASAM 230,000
31 GAMMA GT 40,000
32 GLIKO HB (HBA1C) 116,000
33 GLUKOSA 2 JAM PP 26,000
34 GLUKOSA PUASA 26,000
35 GLUKOSA SEWAKTU 26,000
36 GLUKOSA URIN 26,000
37 GTT (3X : PUASA, 1 JAM, 2 JAM) 58,000
38 KOLINESTERASE 46,000
39 KREATININ DARAH 30,000
40 KREATININ URIN 30,000
41 KURVA HARIAN (3X) 58,000
42 LACTAT 50,000
43 LDH 63,000
44 LIPASE DARAH 96,000
45 LIPASE URIN 96,000
46 MAGNESIUM 41,000
47 MARIJUANA (GANJA) 50,000
48 METAMPHETAMIN (ECTASY) 50,000
 RUMAH SAKIT DR CIPTO MANGUNKUSUMO
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DAFTAR TARIF DEPARTEMEN PATOLOGI KLINIK

NO JENIS PELAYANAN TARIF

49 MIKROALBUMINURIA 78,000
50 MORPHINE (HEROIN, PUTAW,OPIAT) 50,000
51 NITROGEN URIN 34,000
52 NT- PROBNP 306,000
53 OSMOLARITAS PLASMA 45,000
54 OSMOLARITAS URIN 45,000
55 PROTEIN KWANTITATIF URIN 34,000
56 PROTEIN TOTAL 31,000
57 SGOT (AST) 31,000
58 SGPT (ALT) 31,000
59 TRIGLISERIDA 36,000
60 TROPONIN HS 284,000
61 TSH NEONATUS 50,000
62 UREA CLEARANCE 61,000
63 UREUM DARAH 36,000
64 UREUM URIN 36,000

IMUNOLOGI
1 25-OH VITAMIN D TOTAL 239,000
2 AFP 124,000
3 ANA 202,000
4 ANTI DENGUE IGG + IGM 155,000
5 ANTI DS-DNA 214,000
6 ANTI HAV IGM 181,000
7 ANTI HBC IGM 181,000
8 ANTI HBC TOTAL 108,000
9 ANTI HBE 227,000
10 ANTI HBs 76,000
11 ANTI HCV Ig M 465,000
12 ANTI HCV TOTAL 152,000
13 ANTI HELICOBACTER PYLORI IGG 117,000
14 ANTI HELICOBACTER PYLORI IGM 83,000
15 ANTI HIV KONFIRMASI (WB) 624,000
16 ANTI HIV PENYARING 207,000
17 ANTI MULLERIAN HORMON 321,000
18 ANTI -TB IG M 190,000
19 ANTI -TB TOTAL 79,000
20 ASTO KUANTIATIF 78,000
21 BETA 2 GLIKOPROTEIN IGG 190,000
22 BETA 2 GLIKOPROTEIN IGM 190,000
23 BETA HCG (KUANTITATIF) 190,000
24 C3 157,000
25 C4 157,000
26 CA 19-9 217,000
27 CA 125 217,000
28 CA 15-3 268,000
29 CD 14 246,000
30 CD 19 246,000
31 CD 3 + CD 4 + (T HELPER LYMPHOCYTE) 280,000
32 CD 4 119,000
33 CD 56 246,000
 RUMAH SAKIT DR CIPTO MANGUNKUSUMO
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DAFTAR TARIF DEPARTEMEN PATOLOGI KLINIK

NO JENIS PELAYANAN TARIF

34 CEA 152,000
35 CHLAMYDIA TR IgG 275,000
36 CHLAMYDIA TR IgM 275,000
37 CRP (KUANTITATIF) 84,000
38 CRP HS 212,000
39 ESTROGEN 170,000
40 FERRITIN 108,000
41 FREE PSA 328,000
42 FREE T3 103,000
43 FREE T4 103,000
44 FREE TESTOTERON 145,000
45 FSH 161,000
46 FTI (FREE TYHROXINE INDEX ) 228,000
47 H1N1 (RAPID SWAB) 271,000
48 HBeAg 225,000
49 HBsAg 71,000
50 HBV DNA 1,395,000
51 HCV RNA 2,160,000
52 HUMAN IL-6 324,000
53 ICT TB 79,000
54 IGA. 178,000
55 IGE 118,000
56 IGG 118,000
57 IGG ANTI CARDIOLIPIN 125,000
58 IGG ANTI CMV 121,000
59 IGG ANTI HSV 1 146,000
60 IGG ANTI HSV II 146,000
61 IGG ANTI RUBELLA 106,000
62 IGG ANTI TOXOPLASMA 117,000
63 IGM ANTI CARDIOLIPIN 161,000
64 IGM ANTI CMV 127,000
65 IGM ANTI HSV I 146,000
66 IGM ANTI HSV II 146,000
67 IGM ANTI RUBELLA 131,000
68 IGM ANTI TOXOPLASMA 117,000
69 IGM. 182,000
70 IMUNOFIKSASI 404,000
71 INHIBIN B ELISA 361,000
72 INSULIN 89,000
73 LEUKIMIA PHENOTYPING 557,000
74 LH 167,000
75 LYMPHOCYTE CD 45 246,000
76 LYMPHOSIT SUBSET 295,000
77 MYCOPLASMA IgG 275,000
78 MYCOPLASMA IgM 275,000
79 NS-1 ANTIGEN 261,000
80 PAKET CD 34 (TOTAL CD 34 + VIABILITY CD 34 557,000
81 PAKET CD 4 + CD 8 248,000
82 PAKET STEM CELL (CD33, CD 34, DAN CD 133) 701,000
83 PCR HIV (VIRAL LOOD) 644,000
84 PCR HIV (VIRAL LOOD) DISCOUNT 50% 237,000
 RUMAH SAKIT DR CIPTO MANGUNKUSUMO
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DAFTAR TARIF DEPARTEMEN PATOLOGI KLINIK

NO JENIS PELAYANAN TARIF

85 PCR TB 272,000
86 PROCALCITONIN 348,000
87 PROGESTERON 166,000
88 PROLAKTIN 167,000
89 PSA TOTAL 168,000
90 RF. 75,000
91 SALMONELLA IG M 126,000
92 SHBG 121,000
93 T3 102,000
94 T3 UPTAKE 127,000
95 T4 102,000
96 TES KEHAMILAN 33,000
97 TPHA 71,000
98 TSH 102,000
99 TYROGLOBULIN 314,000
100 VDRL 38,000
101 WIDAL 56,000

BAKTERIOLOGI
1 BIAKAN +RES SS DARAH 185,000
2 BIAKAN +RES SS SPUTUM 185,000
3 BIAKAN +RES SS TINJA 185,000
4 BIAKAN +RES SS URIN 185,000
5 BIAKAN AEROB LAIN-LAIN 151,000
6 BIAKAN AEROB PUS 151,000
7 BIAKAN AEROB SPUTUM 151,000
8 BIAKAN AEROB URINE 151,000
9 BIAKAN ANAEROB LAIN-LAIN 311,000
10 BIAKAN ANAEROB PUS 306,000
11 BIAKAN ANAEROB SWAB 306,000
12 BIAKAN ANAEROB URINE 306,000
13 BIAKAN BTA LAIN LAIN 264,000
14 BIAKAN BTA SPUTUM 264,000
15 BIAKAN BTA TINJA 264,000
16 BIAKAN BTA URINE 264,000
17 BIAKAN DARAH SITO (VITEK) 320,000
18 BIAKAN SS+RES SWAB 190,000
19 BIAKAN THAYER MARTHIN 129,000
20 BIAKAN+RES AEROB LKP DARAH 186,000
21 BIAKAN+RES AEROB LKP LAIN LAIN 186,000
22 BIAKAN+RES AEROB LKP PUS 186,000
23 BIAKAN+RES AEROB LKP SWAB 186,000
24 BIAKAN+RES AEROB LKP TINJA 198,000
25 BIAKAN+RES AEROB LKP URIN 198,000
26 BIAKAN+RES AEROB SPUTUM 198,000
27 BIAKAN+RES AEROB TINJA 198,000
28 BIAKAN+RES ANAEROB STD DARAH 387,000
29 BIAKAN+RES ANAEROB STD LAIN-LAIN 387,000
30 BIAKAN+RES ANAEROB STD PUS 387,000
31 BIAKAN+RES ANAEROB STD SPUTUM 387,000
32 BIAKAN+RES ANAEROB STD SWAB 387,000
 RUMAH SAKIT DR CIPTO MANGUNKUSUMO
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DAFTAR TARIF DEPARTEMEN PATOLOGI KLINIK

NO JENIS PELAYANAN TARIF

33 BIAKAN+RES ANAEROB STD URINE 387,000
34 MIC MEROPENEM 129,000
35 PEWARNAAN JAMUR 53,000
36 PULASAN GRAM LAIN-LAIN 32,000
37 PULASAN GRAM PUS 32,000
38 PULASAN GRAM SPUTUM 32,000
39 PULASAN GRAM SWAB 32,000
40 PULASAN TAHAN ASAM DARAH 32,000
41 PULASAN TAHAN ASAM LAIN-LAIN 32,000
42 PULASAN TAHAN ASAM PUS 32,000
43 PULASAN TAHAN ASAM SPUTUM 32,000
44 PULASAN TAHAN ASAM URINE 32,000
45 PULASAN TAHAN ASAM SWAB 32,000
46 PULASAN TAHAN ASAM TINJA 32,000
47 TB ANTIGEN 208,000

HEMATOLOGI
1 AGREGAGSI TROMBOSIT (ADP) 128,000
2 AGREGASI TROMBOSIT (RISTOCETIN) 181,000
3 ANALISA CAIRAN ASITES 181,000
4 ANALISA CAIRAN OTAK 181,000
5 ANALISA CAIRAN PLEURA 181,000
6 ANALISA CAIRAN SENDI 181,000
7 ANALISA CAIRAN TUBUH LAINNYA 181,000
8 ANALISA FESES KHUSUS 225,000
9 ANALISA HB 207,000
10 APT TEST 42,000
11 APTT 64,000
12 ASSAY FAKTOR IX 315,000
13 ASSAY FAKTOR VIII 315,000
14 AT-III 278,000
15 CLOSTRIDIUM DEFFICILE 171,000
16 DARAH SAMAR AB MONOKLONAL 47,000
17 D-DIMER 144,000
18 ECLT (EUGLOBULIN CLOT LYSIS TIME) 107,000
19 ESBACH 32,000
20 FAKTOR VON WILLEBRAND 280,000
21 FIBRINOGEN 58,000
22 FILARIA 30,000
23 G6PD 135,000
24 GAMBARAN SUMSUM TULANG/BMP BAGIAN ANAK 167,000
25 GOLONGAN DARAH 34,000
26 HEMA LENGKAP + GAMBARAN DARAH TEPI 119,000
27 HEMA LENGKAP + GAMBARAN SUMSUM TULANG 167,000
28 HEMATOLOGI KHUSUS (IT RASIO) 71,000
29 HEMATOLOGI LENGKAP 54,000
30 HEMATOLOGI RUTIN 47,000
31 HEMOGLOBIN URIN 41,000
32 HEMOSIDERIN 46,000
33 INHIBITOR F VIII 347,000
34 JUMLAH EOSINOFIL 47,000
 RUMAH SAKIT DR CIPTO MANGUNKUSUMO
RSCM
DAFTAR TARIF DEPARTEMEN PATOLOGI KLINIK

NO JENIS PELAYANAN TARIF

35 LAJU ENDAP DARAH 26,000
36 LE REAKSI 33,000
37 LUPUS ANTIKOAGULAN 311,000
38 MALARIA (ICT+Sediaan) PAKET 95,000
39 MASA PEMBEKUAN LEE&WHITE 26,000
40 MASA PENDARAHAN IVY 37,000
41 MIOGLOBIN URIN 27,000
42 OBERMEYER / INDIKAN URIN 32,000
43 OVAL FAT BODIES 38,000
44 PENYARING F XIII 214,000
45 PERCOBAAN PEMBENDUNGAN 30,000
46 PROTEIN BENCE JONES (TSA 12%) 36,000
47 PROTEIN C 242,000
48 PROTEIN S 242,000
49 PT + INR 45,000
50 PT. 45,000
51 RESISTENSI OSMOTIK 43,000
52 RETIKULOSIT 53,000
53 SEKRET HIDUNG 30,000
54 SEL LE 45,000
55 SUGAR WATER TEST + HAM TES 174,000
56 TES FUNGSI TROMBOSIT ASPIRIN 681,000
57 TES FUNGSI TROMBOSIT P2Y12 681,000
58 THROMBOTES 117,000
59 TINJA 40,000
60 TT (MASA TROMBIN ) 60,000
61 TT SERIAL 163,000
62 URIN LENGKAP 34,000
63 VISKOSITAS PLASMA DAN DARAH (PAKET) 103,000
64 TSH NEONATUS KEMENKES 40,000
65 EVALUASI KIT HIV -

Note : Tarif pemeriksaan belum termasuk alat kesehatan berikut (sesuai harga berlaku):
1 JARUM
2 EDTA
3 GEL NA ACTIVATOR
4 CLOTT ACTIVATOR
5 BACT/ALERT ANAK
6 BACT/ALERT DEWASA
7 KERTAS SARING
8 MEDIA TRANSPORT
9 BODY FLD PRESERV STERIL
10 BODY FLD PRESERV NON STERIL
11 GEL ACTIVATOR
12 WING NEEDLE
13 WADAH PENAMPUNG URIN 24 JAM
14 JARUM AGD
15 HEPARIN